Pre-class information notes

What is the purpose of this week’s nursing tutorial

• Explore how to prepare for and complete a health history interview

• Identify factors that impact your ability to conduct an interview

• Reflect on concerns about asking difficult questions

What is the overall process of a health assessment

• Begins with a primary assessment (DRSABCDE)

• If no life‑threatening issues → proceed to secondary assessment

What does the primary assessment involve

• A rapid assessment of vital physiological functions

• Uses the acronym DRSABCDE to identify immediate threats

What does the secondary assessment include

• Thorough health history

• Physical examination

• Assessment of vital signs

What is the purpose of information gathered during a health assessment

• Identify actual or potential problems the patient may experience

• Plan agreed goals of care with the patient and healthcare team

• Individualise nursing and midwifery interventions

• Evaluate the effectiveness of care delivered by the healthcare team

Where can health history information come from

• Primary source: directly from the patient

• Secondary source: family, carers, or other healthcare professionals

What must be prepared before a health history interview

• Prepare the patient, environment, and yourself

• Ensure privacy

• Provide pain relief if needed

• Good preparation improves data quality and interview effectiveness

How is a health history interview typically conducted

• Confirm name, date of birth, address

• Ask the reason for presentation/appointment

• Review relevant history (e.g., immunisation history)

Why is communication essential in a health history interview

• Builds rapport

• Encourages patients to share important information

• Communication is two‑way: listen, reflect, clarify

• Effective communication ensures accurate, person‑centred care planning

What communication behaviours should be avoided

• Passing judgement

• Using leading questions

• Overusing medical jargon

• Talking too much instead of listening

What confidentiality principles apply to health history interviews

• Information is confidential

• Only shared with the treating healthcare team

• Consult the nurse/midwife in charge before sharing information externally

• Access only the medical records of patients you are directly caring for

• Never access records of celebrities or public figures unless responsible for their care

What should be done when ending a health history interview

• Document all information obtained

• Use the patient’s own words where possible (in quotation marks)

• Organise information logically

• Documentation supports the physical examination and ongoing care